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Should we be moving towards early controlled mobilization of extra-articular hand fractures in BC? Feehan, Lynne Margaret

Abstract

Hand fractures are the second most common fracture in both children and adults. They result in a considerable societal burden related to acute health care costs and lost socio-economic productivity due to a person's limited capacity to perform their normal functional activities throughout their recovery. Although early controlled mobilization (ECM) is commonly used following primary flexor tendon repairs and other equally fragile healing tissues in the hand, it is not commonly recommended for extra-articular hand fractures. There is scientific evidence to suggest that ECM of hand fractures has the potential to enhance early healing, improve regional hand soft tissue function and also lead to an improvement in a person's capacity to function throughout their recovery. However, ECM also may have a negative impact on healing and functional outcomes if introduced inappropriately. To date, the basic scientific and clinical literatures have not identified clear clinical parameters for the 'safe' introduction of ECM following an extraarticular hand fracture. Therefore, the overall objective of this research was to examine the potential clinical efficicacy of ECM following an extra-articular hand fractures as a possible alternative to acute post-fracture immobilization (IM) and to examine the implementation of ECM following an extra-articular hand fracture within the context of its application in the health care system in British Columbia (BC). A series of research inquires were completed, including a five year retrospective review of BC Linked Health Datasets (BCLHD) to define the incidence, demographics and acute health care utilization trends for hand fractures treated in BC; a systematic review of the literature to define the current level of scientifically validated clinical evidence related to early motion following an extra-articular hand fractures; and a pre-clinical efficacy trial examining the effect of early controlled passive motion (ECPM) on 4-point bending structural properties, dorsal fracture alignment and regional mineralized tissue distribution during early fracture healing (initial 28 days) in a closed, extraarticular metacarpal (simulated hand) fracture in a rabbit model. Between May 1,1996 and April 30, 2001 there were 72,481 hand fractures identified in the BCLHD with an estimated 14,500 hand fractures occurring each year in BC with no significant trend for a change over time in number or type of fractures. The annual incidence rate for hand fractures in BC was 36 / 10,000 people. Males were at a 2.1 greater relative risk for sustaining a hand fracture and they sustained most of this risk from the ages of 15 to 40. As well, markedly more hand fractures occurred in the spring and in the Northern Health Authority. In BC, most hand fractures (70%) were initially treated by primary care physicians, with the initial point of contact into the medical care system being either a physician's office or an emergency room setting. Finally, people in BC with more complex hand fracture injuries were referred to and treated quickly by surgeon specialists with only a small percentage (10%) admitted to hospital for management of their hand fracture. Consistent findings from a qualitative synthesis of six Quasi-Randomized Clinical Trials (Q-RCT) indicated that early motion following a simple, closed, extra-articular metacarpal fracture may lead to faster recovery of mobility, strength and return to work without affecting fracture alignment. In addition, in a closed metacarpal fracture in a rabbit model, when compared to fractures treated with IM, fractures treated with ECPM showed significantly (P < 0.05) better gains in 4-point bending initial stiffness (29% difference at twenty eight days), maximum stiffness (21% difference at twenty eight days), failure load (17% difference at twenty eight days) and energy absorbed per unit area (21% difference at twenty eight days), as well as, showing a significant reduction in dorsal fracture angulation (33% difference at twenty eight days). ECPM also had an apparent influence on the mineralized tissue distribution in the callus at the 28-day time period, possibly explaining the superior mechanical properties found in the rabbit healing model at this time point. Hand fractures are a common injury in BC, occurring most commonly in adolescent and young adult males during their most physically active and productive working years. Increased public awareness of hand fracture risk can lead to preventative measures that could reduce the incidence of hand fractures in BC. ECM following an extra-articular hand fracture warrants further randomized clinical investigation in humans as it has the potential to improve fracture healing and functional outcomes. Improved health outcomes following a hand fracture will reduce the socio-economic impact of this common injury in BC. Targeted education regarding the potential benefits of ECM following a hand fracture directed at clinicians treating hand fractures in BC will facilitate the recruitment of patients into future RCTs.

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